Doctors on Call

Amie Lane, a sales trainer for the Container Store at Frisco’s Stonebriar Centre, needed a prescription filled the Saturday after Thanksgiving last year.

Sorry, the pharmacy told her, you have no more refills. You need to talk to your doctor. She called the doctor’s office on Monday. A recording informed her that the office was on holiday and provided no information about when it would reopen.

Tuesday morning, she received an email from Renee Morris, the company’s benefits director, about Teladoc, a telehealth service.

Lane called Teladoc and, in less than 20 minutes, she gave a complete medical history, had conferred with a physician, and had a prescription called in to her pharmacy.

The Container Store launched the program in 2012. Morris says she was initially skeptical when she heard about the telehealth concept. “I worried about potential malpractice,” she says. “But we’ve had a fantastic response. I had to eat my words.”

As primary care becomes scarcer, telehealth has become more mainstream. According to a recent survey by Irving-based Staff Care, many healthcare facilities are seeking to extend their clinical workforce using telemedicine. Forty-three percent of healthcare facility managers said their facilities had integrated telemedicine into at least one of their departments. Of these, 42 percent have integrated telemedicine into radiology, 38 percent into behavioral health, and 24 percent into primary care.

“We’re the pressure-release valve” for primary care, says Jason Gorevic, president and chief executive officer of Dallas-based Teladoc. His company is the oldest and largest U.S. telehealth company.

Teladoc offers physician visits either by telephone or online, depending upon the state. The service allows people to reach a U.S. board-certified doctor or a licensed pediatrician from wherever a member has a computer or a phone. Teladoc estimates the average doctor call-back time is 16 minutes, according to Gorevic. Its physicians use electronic medical records and prescribe electronically. The service is available at all times and costs no more than $38 per consultation.

Teladoc emphasizes that it supplements—not replaces—the family physician.

Although the company does not disclose specific revenue figures, officials allow that Teladoc nearly doubled its annual revenue in 2012 and plans to do so again in 2013. It expects to do 125,000 consultations this year.

Because healthcare is regulated mainly at the state level, Teladoc has to operate flexibly based on local laws. It operates in 49 states and plans to add Oklahoma, which would be the 50th. Texas is one of only a handful of states that does not allow physicians and patients to interact by Internet.

However, Gorevic says, state regulators are “moving toward a recognition that [telehealth] is a necessary solution to some of the cost and access problems in healthcare. Demand from employers and health plans has been very significant. There is finally recognition that it’s very difficult to improve the cost of care without tackling access to care.”

Teladoc has worked with insurers such as Aetna, Blue Shield of California, and Highmark Inc. The company is participating in a program with Aetna for its hundreds of thousands of members in Texas, Alaska, and Florida, where the service is a covered benefit. Teladoc and the insurer promote telehealth as an alternative to the hospital emergency department and for after-hours care. Gorevic says both parties are pleased with initial results.

Waiting List of PhysiciansAccording to a survey by consultant Mercer, about 11 percent of large employers used some form of telemedicine in 2011, and another 38 percent are considering it.

Teladoc uses three primary kinds of physicians: those who are semi-retired or taking time off from active practice; ED physicians who provide services when they are not at the hospital, and actively practicing physicians who treat Teladoc patients between their office appointments.

Gorevic says the company has a waiting list of doctors who want to participate. Physicians generally keep about 90 percent of the visit fees and do not spend time doing paperwork, because patients pay them at the time of the visit by credit card. He says physician satisfaction scores exceed 90 percent.Gorevic says the company does not allow patients to request a specific Teladoc physician because it does not want them to view the service as a substitute for face-to-face care.

“We support the medical home and the need for a family physician. We are a supplement to the primary-care system when you can’t get there,” he says.Teladoc is used as an on-call service for physician practices. In its only direct-to-consumer effort, it charges patients $30 a year for individuals and $50 a year for families as an on-call service for patients of Continuum Health Partners physicians in New York.

Gorevic sees alternative media as growing parts of the company’s business. He estimates about 5 percent of physician-patient encounters use videochat, which he says will grow as people become more comfortable with the technology. Teladoc recently formed a partnership with HealthSpot, a company that provides medical-diagnostic technology in a walk-in kiosk called the HealthSpot Station.

Teladoc recently was named one of the top 10 most innovative companies in health care by Fast Company magazine.

The company’s service is a simple concept, but “very operationally and clinically complex,” Gorevic says. “It is difficult to execute well. I think they recognized us for doing that.”

A Physical ConnectionDevon Herrick, senior fellow at the Dallas-based National Center for Policy Analysis, says Teladoc is an example of trying to address healthcare needs outside of the health-insurance system. He says companies such as Teladoc are more innovative because they have to attract customers.

“This is a daily occurrence in consumer markets, but is absent in healthcare markets because health plans [including Medicare and Medicaid] pay 89 percent of medical bills,” Herrick says. “You can talk to your attorney over the phone; he or she will bill you for his or her time. You can talk to your accountant over the phone. But most people don’t routinely consult with their physician over the phone because insurers are reluctant to pay for telephone consultations. Many health plans will only reimburse for physician visits if they are in-person—even though more than half of all contacts with primary care physicians could be done by email or over the phone.”

Traditional medicine still considers telehealth supplementary to face-to-face visits. Doug Curran, MD, a family physician and member of the Texas Medical Association’s board of trustees, says telemedicine should only be used if a patient/physician relationship has already been established. “TMA believes telemedicine should be used to extend patients’ access to care, while at the same time ensuring the care is delivered in a safe, high-quality manner,” he says. “Patient safety dictates there still needs to be a physical connection to a physician or healthcare provider in the process.”

Tim Howard, MD, does not disagree. The family physician has worked for Teladoc for four years. He handled 32 telehealth patients a day during one recent three-month period, in addition to the 25 he saw at his office in Mobile, Ala. Howard is licensed to practice in Texas and 13 other states as well as in Washington D.C.

“Being able to touch the patients is the perfect situation,” he says. “But doctors use other on-call physicians all the time. And we are better organized than an on-call service.

“There are a lot of pluses. For the patients, there is the convenience,” Howard says. “Many people can’t afford to leave work to go to the doctor’s office for things like rashes, urinary tract infections, and colds. For doctors, it’s the flexibility of practicing anywhere. I have my iPad and my cell phone—that’s my office. That’s a big deal.”

Howard says telehealth is “just a different way of doing what we do every day in our office. It is so much fun to practice medicine without the added hassles. I don’t have payers deciding whether to pay for care. This is old-fashioned primary-care medicine.”